By: Melissa Tanner, Ph.D.
Imagine that you have a clog in your kitchen sink. You decide to use a chemical drain cleaner to dissolve the clog and clear the drain. Unfortunately, in doing so, you inadvertently expose your pipes to harmful chemicals that cause corrosion. The corrosion results in permanent damage to your plumbing system—an outcome that greatly exceeds the inconvenience and cost of the temporary malfunction caused by the clog. Your solution may have fixed the original problem, but the process led to a bigger problem.
What does this have to do with health care? In the plumbing analogy, the sink clog represents a medical diagnosis that precipitates a hospital admission. The process of being hospitalized represents the drain cleaner, and the state of the pipes after being treated by corrosive chemicals represents what is called post-hospital syndrome (PHS). PHS refers to the vulnerable state that results from extended exposure to the environmental stressors associated with hospitalization. This state of heightened vulnerability is often accompanied by an increase in memory and / or other cognitive deficits and leads to an increased risk for adverse outcomes, such as falls, hospital readmission, and mortality. Stressors associated with hospitalization include but are not limited to sleep disruption; hospital-acquired infections; side effects of new medications; deconditioning due to extended bedrest and mobility restrictions; poor nutrition associated with limited access to familiar foods and palatable menu options; separation from loved ones; and the social stress of sharing a room with a stranger. All of these factors contribute to a condition called allostatic overload, which refers to the physiological impact of chronic stress.
Care for patients in hospital and post-acute care settings tends to focus solely on treatment of admitting diagnoses. This makes intuitive sense, but failing to acknowledge and address the stressful context in which the care is delivered may render the progress made with respect to treatment of the original diagnosis meaningless. Nearly 20% of older adults admitted to the hospital are readmitted within 30 days (Goldwater, Dharmarajan, McEwen, & Krumholz, 2018). More often than not, they are readmitted for treatment of a diagnosis that differs from their initial admitting diagnosis (Dharmarajan, Hseih, & Zhenqiu, 2013). This has significant implications for patient care but also has broader financial implications for hospitals. In 2012, the Affordable Care Act (ACA) established The Hospital Readmission Reduction Program, which financially penalizes hospitals for having higher than expected risk-standardized 30-day readmission rates. Given that PHS is often implicated in hospital readmissions, it makes sense from both a clinical and a financial perspective to take a proactive approach to preventing and / or mitigating the effects of PHS (Goldwater et al., 2018).
Some proposed solutions to preventing PHS include systematic efforts directed at improving the experience of hospitalization. This includes limiting night-time sleep disruptions, controlling ambient noise, encouraging safe exercise and ambulation, and ensuring satisfaction of nutritional needs. While these are good suggestions in theory, they require widespread culture change and are likely to take a long time to enact. Other proposed solutions approach the problem from a different angle, targeting vulnerabilities like impaired cognitive performance and associated functional decline, which contribute to the heightened risk of rehospitalization.
To address PHS and improve functional outcomes, the BCAT® research center designed a cognitive intervention program intended to be applied concurrently with functional remediation in post-acute care settings. The intervention draws upon neuropsychological theory and empirical support establishing a link between working memory and functional skills. In order to test the hypothesis that integration of a cognitive rehabilitation program with functional deficit remediation would result in improved functional outcomes, thereby reducing risk of rehospitalization, the BCAT® research center conducted a randomized, controlled trial of 65 skilled nursing home patients. Results demonstrated that patients concurrently receiving both the BCAT® cognitive intervention program and traditional functional remediation showed greater improvements in overall functional performance over time than control patients receiving only functional interventions. In other words, utilizing the BCAT®’s cognitive intervention program in addition to traditional functional remediation programs produced “better and faster” outcomes with respect to post-acute rehabilitation, thereby expediting patients’ safe discharges home—and away from the stressful experience of inpatient care.
Returning to the sink analogy, pipes that have been exposed to corrosive substances are more vulnerable to leaks and / or permanent damage to the entire water system. Similarly, older adults who experience allostatic overload as a result of a hospitalization are more vulnerable to a host of negative health outcomes. While there may be safer alternatives to chemical drain cleaners, avoiding hospitalization and undergoing less stressful outpatient treatment is not usually a viable alternative for most people. Therefore, we must recognize hospitalization as a reality and identify ways to reduce vulnerability to PHS. The BCAT® Research Center proposes two pathways to accomplish this goal:
1. Integration of the BCAT®’s cognitive interventions with traditional functional remediation programs in sub-acute care settings. This has been shown to produce “better and faster” outcomes, which could reduce risk of rehospitalization. Stay tuned for our upcoming research publication, which provides empirical support for this finding.
2. Use of BCAT®’s cognitive interventions, like the Working Memory Exercise Book or the Brain Rehabilitation modules, by healthy older adults. Even those who have not experienced a recent hospitalization can benefit from interventions designed to build neuroplasticity and cognitive reserve. Strengthening a brain’s defenses against trauma and diseases that can compromise cognitive functioning helps guard against PHS.
As always, visit the BCAT® blog for updates on cutting edge research and advances in the field of brain health.